• Transcend STEM Community Action Intake & Consent Form

    Transcend STEM Community Action Intake & Consent Form. This application is for Housing Assistance *PLEASE COMPLETE INFORMATION TO THE BEST OF YOUR KNOWLEDGE*
  • Application Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Gender*
  • Format: (000) 000-0000.
  • Race*
  • Ethnicity*
  • Education*
  • Have you served in the military?*
  • Health Insurance*
  • Family Type*
  • Are you disabled?*
  • Employment*
  • Income(s)*

  • You are REQUIRED to provide income verification through any of the following:

    • Pay stubs (last 30 days)
    • DIS (last 30 days)
    • Employer letter (last 30 days)
    • SSI/SSD payment sheet
  • Does anyone in your household have any of the following?*
  • Have you or anyone in your household received services through Transcend STEM Education?*
  • Check all the barriers present:*
  • Domestic Violence*

  • Expenses within the last 30 days:

    Car Payment:   *   
    Groceries:   *   
    Miscellaneous:   *   
    Rent:   *   
    Insurance:   *   
    Mortgage:   *   
    Gasoline:   *       

  • In this section please include ALL MEMBERS of the household*
  • Barriers*
  • Income(s)*

  • You are REQUIRED to provide income verification for all people over 18 years old receiving income through any of the following:

    • Pay stubs (last 30 days)
    • DIS (last 30 days)
    • Employer letter (last 30 days)
    • SSI/SSD payment sheet

  • Authorization to Release Information

  • "I,   *   *   , give Transcend STEM Education consent to release, obtain, and share all pertinent identifying and non-confidential social, medical, and other information about myself that will allow me to benefit from services offered. In granting such permission, I understand that such information will remain confidential and that such information will only be used for my benefit or to benefit other members of my family.
    The statements made by me on this consent for are true, correct, and complete to the best of my knowledge"

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Self-Sufficiency Statement

    According to the Community Service Block Grant, "self-sufficiency" is defined as: the applicant needs to be achieving (or working towards) a set of goals which will result in greater self-sufficiency and will eliminate some of the causes of that family's poverty. What issues is the applicant facing and the resources the family (or community agencies the family is working with) bring to address these issues.
  • Are you able to utilize another transit source? *(if you are within 3/4 of a mile of a bus stop, you have a transit source and are ineligible for this program)*

  • Scholarship Program

  • Have you applied for financial assistance?
  • Will this degree/certification/education allow you to provide for yourself?

  • Housing/Rental Assistance

    (Does not cover mortgages. Contact Homeownership Made Easy for mortgage, closing costs, or down payment assistance 214-770-1252)

  • According to HUD, chronic homelessness means*:
    (1) A homeless individual or head of household with a disability that meets the HUD definition of a disability who

    • (a) lives in a place not meant for human habitation, a safe haven, or in an emergency shelter;
      AND
    • (b) has been homeless and living in one of these places continuously for at least 12 months OR on at
      least 4 separate occasions in the last 3 years, as long as the combined occasions equal at least 12
      months and each break in homelessness separating the occasions included at least 7 consecutive
      nights of not living in one of the aforementioned places.
      Stays in institutional care facilities for fewer than 90 days will not constitute a break in homelessness
      or other similar facilities.

  • Are you chronically homeless?*
  • Can you turn utilities in YOUR name?*
  • Have you utilized CEAP for utility assistance?*

  • Client Application Acknowledgement

  • Transcend STEM Education Program partners with several organizations to assist families experiencing a housing crisis, unemployment, career changes or needing Education Assistance. The authorization is designed to permit those organizations to share client information in order to collaborate on services and promote stability.

  • *
     - -
    2 digit month, 2 digit day, 4 digit year

  • Privacy Policy and Termination Disclosure Statement

    Acknowledgement of Receipt

  • Information to be released: I understand authorized personnel will share client information needed for service, delivery, program eligibility, to track demographic trends, service patterns and the client outcomes achieved.

    For the purpose of: I understand this is for the purpose of (a) providing coordinated housing, medical, social, psychological, and other service to me, (b) evaluating the outcomes related to service delivery, and (c) to improve coordiantion of services to assist individuals and families experincing a crisis, and (d) to identify barriers and service gaps that block the path out of poverty. In the event of the publication of the results of the program, my identity will be kept confidential, although information about my circumstances may be discussed. 

    Right to revoke: I understand this authorization is subject to revocation at any time except to the extent that the agencies which are to make the disclosures have already taken action in reliance on those disclosures. 

    Potential Re-Disclosure: I understand that information that I authorize to be disclosed may be re-disclosed and not subject to medical privacy regulations.

    Program Rules Privacy Policy and Termination Policy: I understand that there are Program Rules to be adhered to and by signing below I acknowledge receipt of the Program Rules, Privacy Policy, Termination Policy and Grievance procedures.

     

     

  • By signing below, I acknowledge receipt of privacy policies and termination disclosure and I understand the information provided.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
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